mPEAK Course Registration

    mPEAK Course Date/Time

    Personal Information

    This information will be stored in a secure location and will not be shared without your permission. Only the course teachers will have access to this information. 

    Emergency Contact 

    Demographic Information

    Getting to Know You:

    Participation Acknowledgement and Waiver:

    I accept full responsibility for my health and voluntarily complete this Acknowledgement and Waiver of Liability. I understand and agree that the services and tools offered in the mPEAK (Mindful Performance Enhancement, Awareness and Knowledge) programs offered by Dr. Carli Kody and teachers/coaches, are not intended to replace or be substituted for medical or psychiatric care. It is recognized that the trainings inherent in the programs may at times make participants feel vulnerable. mPEAK programs are not therapeutic interventions for psycho-pathological disorders as defined in the DSM, and are not intended as such. By completing this release and consent I assume all risk for any physical or mental consequences of participating in the program. By signing this release I also specifically and expressly agree to hold harmless, indemnify and release the teachers of this course and Carli Braun Kody, PhD, LP, LLC, its officers, employees and agents from any and all liability for the results of the educational guidance that will be or have been provided. Moreover, I acknowledge that the particulars shared in these classes by other participants are to be maintained as confidential. I will not blog or otherwise report on content shared in these classes in any form of media.

    By typing my name below, I am indicating that I understand and accept the above terms of this Participation Acknowledgement and Waiver of Liability.

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